in- home chart: maximizing palliative practice · in- home chart: maximizing palliative practice...

A Partnership for Caring:Central CCAC, Southlake Regional Health Centre &Temmy Latner Centre for Palliative Care

In- Home Chart:

Maximizing Palliative Practice

Educational Sessions presentation by

Hospice Palliative Care Teams for Central LHIN

October 2009

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Purpose

To share client information with palliative care team members, including the family.

To assess client needs, concerns, and manage salient client/family issues.

To record & document care in one central location to be accessed by all care service providers and family members.

In-Home Chart

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A Partnership for Caring:

Central CCAC, Southlake Regional Health Centre &Temmy Latner Centre for Palliative Care

Goals of the In-Home Chart

Improve communication among team members

Reduce duplication of information collected

Integrate Edmonton Symptom Assessment

System (ESAS) and Palliative Performance

Scale (PPS) tools

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Initiating the Record of Care

The Primary Nurse will:

1. Initiate the In-Home Chart

and

2. Explain the purpose and use of the Chart to the client/caregivers

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The In-Home Chart is a legal document and communication tool

Client/caregiver/care providers will be able to document symptoms and concerns in progress notes in the home

Upon discharge:

The entire chart will be returned to the agency

Initiating the Record of Care

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Primary Nurse Responsibilities

At each visit the Primary Nurse will:

Sign in

Ensure the Clinical Assessment Tool is completed within the first three nursing visits

Label appropriate flow sheets for use

Instruct the Client to use ESAS

Assess and document PPS

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Primary Nurse Responsibilities (cont)

Assess, monitor, record, address client concerns and status

Check Progress Notes for updates

Update Demographics and Advance Care Planning as needed

Report as required to the CCAC Case Manager / MD

Reorder chart forms and flow sheets from own agency (CADD, wound care, etc.) as required

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Record of Care

Highlights

of

Sections

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Front CoverCare Team Contact Sheet:

Contact information for the client’s care team

is listed for easy access

Client’s Name, Phone & BRN #

Pharmacy Contact #

Main Caregiver Contact #

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Sign In Sheet:

Every team member is to ‘sign in’

The most current sheet on top

Sign In Sheet

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Section 1: Demographics & Initial Clinical Assessment

Demographics:

Includes pertinent contact and

client information

To be filled out by the nurse on the

first visit

Advanced care planning

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Section 1: Demographics & Initial Clinical Assessment (cont)

Initial Assessment Tool:

A comprehensive tool to guide your care plan

Mandated to be completed within the first

three (3) visits*

ESAS and PPS are new additions

*(Source: Preferred Practice Guidelines for Palliative Care Nursing)

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Section 2: Doctor’s Orders

Allergy List Doctor’s Orders

Initial Allergy List located on the left

of MD orders

MDs will document orders with the

most current orders filed on top

A detail list of allergies is checked

regularly and updated by all team

members

RNs will check & initial orders

Precautions and Risk/Infectious

Diseases

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Section 3: Medication List

Regular & PRN Medication List MAR for Regular & PRN Medications

List of all past, current and PRN

medications

Documentation of every drug

administered by an RN

Update MAR with every new

medication order

Document with the most current sheet on top

** Additional forms from your agency can be added to this section

for your patient’s needs (e.g. CADD flow)

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Section 4: Nursing

Clinical Assessment Flow Sheet

A comprehensive flow sheet to capture

the client’s health status

Abnormal findings should be

documented in the Progress Notes*


** Additional forms from your agency can be added to this section for your patient’s needs (e.g. Wound care, etc)**

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Edmonton Symptom

Assessment System (ESAS) is a

gold standard for symptom

assessment

It is the client’s opinion of the

severity of the symptoms

The severity at the time of

assessment of each symptom is

rated from 0 to 10 on a numerical

scale; with 0 meaning that the

symptom is absent and 10 that it is

the worst possible severity.

ESAS

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Palliative Performance Scale is a reliable communication tool used by HCPs for palliative care clients that guides the assessment of a

patient’s functional performance.

PPS

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Common Assessment Tool (CAT Form)

Documentation of the ESAS and PPS to be completed

at each visit

If there are no significant changes can be charted

weekly at nurse’s discretion

Mark PPS score with * if Progress Note is written

Fax completed forms to your agency every month

Section 4: Nursing (cont)

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Interdisciplinary Symptom

Management Guidelines

Used as assessment tool for ESAS

scores > 4

Document extraordinary/abnormal

findings, and actions/interventions in

Care Plan and Progress Notes


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Care Plan

To record client’s concerns

The Collaborative Care Plan is a guide for the health care

team to address patient-centred interventions and states

expected outcomes for care.*

Mandated to be completed by HCPs and consent confirmed

with client

Must be continually assessed and update

* Refer to: Collaborative Care Plans: PCIP Collaborative Care Plans – “Lite”

Version


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Care Team Progress Notes

A communication space for EVERY team member

including family, caregivers, and hospice volunteers

to communicate with each other regarding client’s

concerns, changes in status, etc.

Document by exception


To be checked by all team members

at each visit for updates

Section 5: Progress Notes

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The DNR Confirmation Form or the EDITH protocol is to be inserted on the inside pocket of the chart for easy access.

Advanced Directives

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Key Points

• Increase communication!

• Streamline documentation

• First step to including interdisciplinary team

• Standardization of palliative practice

• No change in policy and procedure – Contact manager with further questions

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We are dedicated to continuous quality improvement and want your feedback!

We would greatly appreciate your comments and suggestions regarding the improvement of the

In-Home Chart.

Please e- mail or fax us any issues, concerns, Suggestions - big or small!

We want this to work for everyone!

Catherine Bazowsky: [email protected]

Fax #: 905-473-7055

Evaluation

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mailto:[email protected]

in- home chart: maximizing palliative practice · in- home chart: maximizing palliative practice...

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